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Y <br /> �( SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 5�;­TFFICE USE: ry� �� 601 E. Hazelton Ave. , Stockton, CA 95205 Perm'�t,No: <br /> hone <br /> Tel e :'-,� �209 466-6781 <br /> p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> t1oanuin County Ordinance No. 1862 and the Rules an Regulations of th Sari Joaquin Local Health <br /> District. .- <br /> EXACT STREET ADDRESS 5 TY/TOWN --�— <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name '_cense# () Phone ?-'?-1,63Z <br /> IS CERTIFICATE OF W ftKIZAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YESt NO <br /> TYPE OF WORK (Check) : NEW WELL&r---'DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL. CHLORINATION -❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION 0 PUMP-REPAIR❑ PUMP REPLACEMENT ❑ W <br /> DISTANCE TO NEAREST: SEP-TIC•-TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATJOS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia. of Well Casing <br /> omestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Retary Type of Grout ` <br /> Disposal Other Other Information <br /> Geophysical � ,. Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR• []State Work Done _.,.. ,.. .....,.,..—,._ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material ana Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed agent'ssign ture cer 'fies the following: <br /> "I certify that in the performance of the work f r which thi permit is issued, I shall <br /> not employ any person in such manner as to. beco <br /> laws of Calif rn ' " = <br /> e subject o Wor n' s Compensation <br /> I WILL CALL FOR G UT INSPECTION P 0 TO GROUTING A - NAL S T <br /> SIGNED2, --` fft E: DATE: <br /> 4RPLOT PL N ON R SE SIDE <br /> FOR DEPARTMENT SE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DAT E--�--1 ' <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY (���„! DATE <br /> EH 1426 Rev. 12-77 _ _-- 1 /78 2M <br />